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DocuSign Envelope ID:AAB48FBD-7E41-49ED-AF28-FCE317917B07 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> This endorsement, effective 6/3/16 at 12:0AM,Eastern Standard Time, forms a part of <br /> Policy No: CRS0000057 of Carolinas Roofing&Sheet Metal Contractors Self Insurers Fund <br /> Issued to: Pickard Roofing Company,Inc. Effective: 01-01-2016 to 01-01-2017 <br /> P 0 Box 76 <br /> Durham,NC 27702 <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br /> WC 00 03 13 <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br /> enforce our right against the person or organization named in the Schedule. This agreement applies only to the <br /> extent that you perform work under a written contract that requires you to obtain this agreement from us. <br /> This agreement will not operate directly or indirectly to benefit any one not named in the Schedule. <br /> SCHEDULE <br /> Certificate Holder: Orange County NC <br /> P 0 Box 8181 <br /> • Hillsborough,NC 27278 <br /> Project: Old Orange County Court House <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br /> stated, <br /> j ( t r )A, <br /> Atfthorized Representative <br /> } j <br /> (Ed. 4-84) Copyright, 1983 National Council on Compensation Insurance <br /> • <br />